Healthcare Provider Details

I. General information

NPI: 1326236514
Provider Name (Legal Business Name): SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10570 BLUE STAR M HWY
SOUTH HAVEN MI
49090-8923
US

IV. Provider business mailing address

PO BOX 2078
PORTAGE MI
49081-2078
US

V. Phone/Fax

Practice location:
  • Phone: 269-639-1115
  • Fax: 269-639-2525
Mailing address:
  • Phone: 269-639-1115
  • Fax: 269-639-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001629
License Number StateMI

VIII. Authorized Official

Name: DR. REGINA LYNNE SPEARS
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 269-639-1115